Provider Demographics
NPI:1538198619
Name:OLIVE SURGERY CENTER
Entity type:Organization
Organization Name:OLIVE SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIVISION VP
Authorized Official - Prefix:MS
Authorized Official - First Name:LUANN
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-906-1510
Mailing Address - Street 1:12101 WOODCREST EXECUTIVE DR. SUITE 101
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141
Mailing Address - Country:US
Mailing Address - Phone:314-576-4500
Mailing Address - Fax:314-576-4503
Practice Address - Street 1:12101 WOODCREST EXECUTIVE DR STE 101
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-5047
Practice Address - Country:US
Practice Address - Phone:314-576-4500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO177-0261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK201928OtherBLUE CROSS BLUE SHIELD